The responses of the Public Health
Departments in Europe and in the United States represented the ideas
prevalent in society and in the scientific community. While most of
the measures were solidly grounded in the current scientific concepts,
they could also be traced back to Medieval and even Classical times of
plague and pestilence. The idea of contagion prompting quarantines
and isolation dates back to the Justinian Plague. However,
epidemiological work by Snow and others in the 19th century did further
these notions of contagion and understanding of transmission. Public
Health Departments grew out of these advances and the belief in the
ability of man to control nature. Sanitation, vaccination programs and
other public hygiene efforts in the late 19th century enabled public
health officials to gain power and authority. However, the
Influenza Pandemic of 1918-19 challenged the public health agencies.
The massive morbidities from the common illness of influenza were
mysterious and frightening. Many of the measures formerly known to
work were ineffective. They were not prepared for an event of this
magnitude, lacking the organization and infrastructure and constrained
by the war. Yet, the great war provided the rhetoric of nationalism
necessary to usher in these authoritative responses and losses of
liberty.

Authoritative Measures

The public health authorities in both the United States and
Europe took up fundamental measures to control epidemics that dated
back to Medieval times of the Bubonic Plague. They aimed to reduce the
transmission of the pathogen by preventing contact. They framed their
public health orders in scientific ideas of
their understanding of how the influenza microbe spread through the air by
coughing and sneezing, and their conception of the pathogenesis of
influenza.
Since they concluded that the pathogen was transmitted through the
air, efforts to control contagion were organized to prevent those
infected from sharing the same air as the uninfected. Public
gatherings and the coming together of people in close quarters was seen
as a potential agency for the transmission of the disease. The
public health authorities believed that good ventilation and fresh air
were "the best of all general measures for prevention, and this implies
the avoidance of crowded meetings," (BMJ, 10/19/1918). This translated
into the controversial and imperative measure of closing of many public
institutions and banning of public gatherings during the time of an
epidemic.

The rigidity of these regulations varied immensely with the power
of the local health departments and severity of the influenza outbreak.
In the United States, the Committee of the American Public Health
Association ( APHA)
issued measures in a report to limit large
gatherings. The committee held that any type of gathering of people,
with the mixing of bodies and sharing of breath in crowded rooms, was
dangerous. Nonessential meetings were to be prohibited. They
determined that saloons, dance halls, and cinemas should be closed and
public funerals should be prohibited since they were unnecessary
assemblies. Churches were allowed to remain open, but the committee
believed that only the minimum services should be conducted and the
intimacy reduced. Street cars were thought to be a special menace to
society with poor ventilation, crowding and uncleanliness. The
committee encouraged the staggering of opening and closing hours in
stores and factories to prevent overcrowding and for people to walk to
work when possible (JAMA, 12/21/1918). Some of the regulations in
Britain were milder, such as limiting music hall performances to less
than three consecutive hours and allowing a half-hour for ventilation
between shows (BMJ, 11/30/1918). In Switzerland, theaters, cinemas,
concerts and shooting matches were all suspended when the epidemic
struck, which led to a state of panic (BMJ, 10/19/1918). This
variation in response was most likely due to differences in authority
of the public health agencies and societal acceptance of their measures
as necessary. This necessitated a shared belief in the concept of
contagion and some faith in the actions of science to allow them to
overcome this plague.

An American school in the 1910s

The most frequently discussed and debated public health measure in
the journals of the period was the closure of the schools. In Britain
the prevalence of the epidemic led to the closure of the public
elementary schools (BMJ, 11/30/1918). In France, students with
any symptoms and their siblings were to be excluded from school. If
three fourths of the students were absent then the whole class was to
be dismissed for 15 days (JAMA, 12/7/1918). Some believed
closing schools to be a useful measure to control infection but
complained that it often occurred too late, after most students and
teachers were sick (BMJ, 10/19/1918). In the United States, school
closure was not as widely accepted. One article in JAMA said
that, "the desirability of closing schools in a large city in the
presence of an epidemic is a measure of doubtful value," (10/5/1918).
The APHA Committee debated its value too, questioning the effectiveness
against the loss of educational standards. Generally, school closure
was thought to be less effective in large urban metropolises than in
rural centers where the school represented the point of dissemination of
the infectious agent.
The closing of schools and other public institutions as public health
regulations to reduce the epidemic was not universally accepted. One
editorial in the BMJ states that "every town-dweller who is susceptible
must sooner or later contract influenza whatever the public health
authorities may do; and that the more schools and public meetings are
banned and the general life of the community dislocated the greater
will be the unemployment and depression," (12/21/1918).

The more restrictive methods of infection control issued by
public health departments were quarantines and the isolation of the
ill. These measures required a sacrifice of individual liberty for the
societal good and therefore required a strong public health authority.
Both the Illinois and New York State Health Departments ordered that
patients must be quarantined until all clinical manifestations of the
illness subsided. They held that the danger of the influenza epidemic
was so grave that it was imperative to secure isolation for the patient
(JAMA, 10/12/1918). The members of the APHA committee agreed in their
report, saying that patients with influenza should to be kept in
isolation. Because of the strain on facilities, only severe cases were
to be hospitalized while mild influenza patients were to remain at
home. The APHA also supported institutional quarantines to protect
people from the outside world in establishments like asylums and
colleges (JAMA, 12/21/1918). The use of institutional quarantines was
applied to the many military training camps set up in the United
States to prepare soldiers for war. These camps, with masses of men
from throughout the country, were prime targets of huge influenza
epidemics. The men were kept in strict isolation once ill and entire
camps was often quarantined (JAMA, 4/12/1919). These measures were
easily implemented in these camps where men were already committed to
their country and the authority of the government.

Preventative Measures

The Committee of the American Public Health Association (APHA)
issued a report outlining appropriate ways to prevent the spread and
reduce the severity of the epidemic. They noted first that the disease
was extremely communicable and "spread solely by discharges from the
nose and throats of infected persons." They sought to prevent
infection by breaking the channels of communication such as
droplet infection by sputum control. They believed that infection
occurred by the contamination of the hands and common eating and
drinking utensils. Thus they called for legislation to prevent the use
of common cups and to regulate coughing and sneezing. They wanted to
initiate education programs and publicity on respiratory hygiene about
the dangers of coughing, sneezing and the careless disposal of nasal
discharges. They aimed to teach people the value of hand-washing
before eating and the advantages of general hygiene (JAMA, 12/21/1918).
Public Health Departments issued Flu Posters to educate
the community and reduce the spread of infection. The members also
noted that the response should vary according to the type of community
and the living conditions. Measures were to be adapted to rural or
metropolitan areas, with a centralized coordination to enforce
compulsory reporting and canvassing for cases.

Public Health agencies applied the principles of contagion to
methods of hygiene and a regard for ventilation in their suggestions
for reducing the spread of the illness and preventing disease. They
held that well ventilated, airy rooms promoted well-being, (BMJ,
11/16/1918). Preventative measures built upon the same ideas of
transmission and the germ theory of
disease. These ideas were
practiced in the hospitals as special influenza wards for influenza
patients were created and the number of beds per ward was decreased to
reduce the transmission of the disease. Those with complications such
as pneumonia were separated from the rest to prevent the others from
progressing to this more fatal state (BMJ, 11/2/1918). Sheets were
hung between the beds to mimic isolation in limited closed quarters to
provide a cubicle for each patient. No patient was allowed to leave
their bed until they were fever free for 48 hours. In the military
camps, soldiers were instructed to eat 5 feet apart in the mess halls.
Head to foot sleeping was also implemented to reduce the sharing of air
space (JAMA, 4/12/1919). One camp used these ideas of prevention via
ventilation and boasted of their results. They claimed their rampant
influenza epidemic terminated once men were kept out in the open with
sunlight or in open, airy halls and prevented from gathering (JAMA,
12/14/1918).

One of the key aspects of prevention was the use of disinfection
and sterilization methods. The practical prevention guidelines
utilized the recent developments made by Lister and others of the
necessity antiseptic conditions. All bedding and rooms were to be
periodically disinfected to kill whatever pathogen pervaded them. In
naval ambulance trains this was executed by washing down the train with
a weak izal antiseptic solution (BMJ, 11/23/1918). The produced
sputum, thought to be riddled with the microbe, was to be destroyed.
In one hospital the sputum cups were emptied and disinfected twice
daily, while nasal discharges were collected in paper napkins. An
antiseptic hand solution was placed conveniently for those on duty in
the influenza ward (JAMA, 4/12/1919). One French report also suggested
that the staff of influenza wards should wear blouses inside the ward
and remove them when leaving (BMJ, 11/2/1918). These disinfection
procedures of prevention utilized scientific ideas of germ theory to
reduce transmission.

The gauze mask was another prevention method using similar ideas of
contagion and germ theory. In the United States it was widely accepted for
use in hospitals among health care workers. The face masks consisted of a half
yard of gauze, folded like a triangular bandage covering the mouth, nose and chin
(BMJ, 11/2/19118). These gauze masks acted to prevent the infectious
droplets from being expelled by the mouth and from the hands, contaminated with
microbe from being put to the mouth. The barrier from the hands was thought
to be more important than the barrier from the air. The mask was also worn
in some regions by the general population. In San Francisco the gauze
masks were made a requirement of the entire population in a trial
ordinance. This was later expanded to include San Diego in December.
This rhyme was a popular way to remind people of the ordinance.

Obey the laws

And wear the gauze

Protect your jaws

From Septic Paws

They found that the mask wearing led to "a rapid decline in the number of
cases of influenza," (JAMA, 12/28/1918). A study in the Great Lakes, however, did not find such
beneficial results. Mask wearing by hospital corps did not have an effect on the
incidence of disease as 8% who used the mask developed infection while only 7.75% of
non-mask wearers did (JAMA, Vol. 71, No. 26). Despite these results, the
masks were commonly used by many in an effort to avoid the pandemic influenza
disease.

Prophylaxis

The members of the APHA committee also suggested ways to increase the
natural resistance to the illness. They stated that nervous and physical
exhaustion should be avoided. People were encouraged to maintain proper
rest, to get fresh air and maintain general hygiene. The French report
also encouraged avoiding over-fatigue and exposure to the cold (BMJ, 11/2/1918).
The Royal College of Physicians shared this opinion saying that the chilling
of the body should be prevented by wearing warm clothing out of doors. They
also claimed that good nourishment of food and drink was desirable, saying that
chill and over-exertion...have evil consequences," (BMJ, 11/16/1918).
These methodologies unlike the preventative measures do not appear to have a
strong scientific basis. Rather, they reflect common societal ideas about
the wellness and the ability to fight infection. Thus to a degree, the medical
and public health officials were still using common sense notions to
combat this new infectious terror.

One method of preventing infection, however was more scientific, more
elaborate and more controversial. This was the gargling and rinsing out of
the nasopharynx with antiseptic solution. Physicians held that since the disease
was transmitted through the upper respiratory passages, it made sense to
disinfected the nose and mouth to prevent infection. One method was to gargle with warm
water mixed with chlorinated soda. A Dr. F. W. Alexander recommended
electrolytic disinfection fluid as mouth wash for influenza to be gargled and
sniffed up the nose (BMJ, 11/2/1918). Others gargled and sprayed the
nasopharynx with a weak solution of carbolic acid and combined it with
quinine to prevent infection (BMJ, 11/23/1918). A more serious method of cleansing
and disinfecting the nasal spaces and upper air passages was suggested by Dr.
James Bach. He advocated a powder of boric acid and sodium bicarbonate. The
powder was to be blown into the nose which would then dissolve and by
osmotic pressure induce mucus flow to wash the membranes (JAMA,
12/7/1918).
This method has a scientific basis but little scientific proof of
efficacy. They worked as well as some of the treatments invented to cure influenza
which were based on scientific ideas but not scientific results.
The APHA members believed that gargling had no value as they cleared out the
protective mucus barrier to infection.

The American Public Health Association committee members believed that
the best way to prevent infection was through the use of vaccines. Vaccines
could prevent or mitigate infection with influenza and the frequently
fatal complications of the illness due to the influenza bacillus or
strains of streptococci and pneumonococci. They believed that the current
vaccines under development should
be tested and administered if useful to prevent infection. The committee
suggested the use of the experimental vaccines on susceptibles with equal
subjects and controls and under proper scientific methodology. However,
they acknowledged that the cause of the influenza was unknown and
therefore an effective vaccine had no "scientific basis," (JAMA,
12/21/1918). These public health officials shared the perceptions of the
scientific and medical community of the
influenzal disease and its origins.